Provider Demographics
NPI:1316150774
Name:REARDON, JANICE ELLEN (DDS)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:ELLEN
Last Name:REARDON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 85200
Mailing Address - Street 2:MAIL CODE 1300
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78708-5200
Mailing Address - Country:US
Mailing Address - Phone:512-491-2060
Mailing Address - Fax:
Practice Address - Street 1:11501 BURNET RD
Practice Address - Street 2:BUILDING 902
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-3407
Practice Address - Country:US
Practice Address - Phone:512-491-2060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13939122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist